The present invention relates to a new surgical procedure for hemorrhoids.
Hemorrhoids are essentially normal parts of human anatomy and it is considered a disease of western civilization. It is extremely rare in rural Africa due to, In principle, high fiber diet consumption. Contributing factors include heredity, anatomical features, nutrition, exercise, occupation, psychological problems, senility, endocrine changes, food and drugs, straining, constipation, diarrhea, and inflammatory bowel diseases and intestinal neoplasm.
It is difficult to figure out the exact incidence and prevalence of hemorrhoids because primary care physicians will screen and treat patients who may or may not have hemorrhoids but have hemorrhoidal symptoms. Many patients with hemorrhoids choose not to come for consultation and will treat themselves with ointments, creams, lotion or application of cold or heat. In 1990, Johnson and Sonnenberg studied the prevalence of hemorrhoids and chronic constipation and estimated that ten million people in the United States complained of hemorrhoids, a prevalence rate of 4.4%.
The real cause of hemorrhoids is not known. There is no single theory that could explain the occurrence and the frequency of hemorrhoids. It depends, most probably, on many factors. The very attractive theory of xe2x80x9cvascular cushionsxe2x80x9d of Thomson described in 1975 does not explain the occurrence of hemorrhoids in young mate and female between 20-30 of age where there is no deterioration or weakening of supporting and anchoring tissue of hemorrhoids. In youngster, the occurrence of sudden, localized in one portion, thrombosed hemorrhoids is more frequent. On the other hand, hemorrhoids are not that frequent in old population where aging could be considered a more plausible factor. In his theory, Thomson propose that normal hemorrhoidal tissue represent discrete masses of thickened submucosa, which slide with straining efforts of defecation. These vascular cushions become engorged with blood and serve some sort of function in the canal anal, preventing the escape of fluid, gas, or solid fecal material. With the passage of time, anatomic structures supporting the muscularis submucosae weaken and lead to slippage or prolapsation with subsequent symptoms such as bleeding, engorgement, burning and discomfort.
There are three main cushions in the anal region; the left lateral, the right anterior and the right posterior one. The anal cushions receive their blood supply from the terminal branches of the superior hemorrhoidal artery (superior rectal artery) and to a lesser extent, from branches of the middle hemorrhoidal arteries. These branches communicate with one another and with branches of inferior hemorrhoidal arteries, which supply the lower portion of the anal canal. The superior, middle and inferior hemorrhoidal veins, which drain blood from the tissues from the anal canal, correspond to each of hemorrhoidal arteries.
Haas et al have noted microscopically, deterioration of supportive tissue by the third decade of life.
Stelzner et al thought that swollen tissue of anorectum might represent xe2x80x9ca corpus cavemosumxe2x80x9d as they demonstrated numerous arteriovenous communications in the anal region.
Constipation is incriminated as a cause of hemorrhoids; however, only less than 20% of patients operated on for hemorrhoids complain of constipation. Diarrhea is known to cause hemorrhoids to flare. Gibbons et al. investigated chronic constipation, bowel habits, and pressure profiles, and anal compliance and found that symptomatic hemorrhoids were associated with significantly longer anal pressure zones as well as greater maximum resting pressure at all levels of anal distention.
Hyperactive sphincter found before hemorrhoidectomy returns to normal after surgery, but the relationship is not that clear.
Hemorrhoids are classified by their location (external, internal, or mixed) or by degree (first, second, third, and forth).
External hemorrhoids arise from the inferior hemorrhoidal plexus and are covered by anoderm, which is modified skin epithelium, bearing no skin appendages. They are situated below the dentate line. Distribution is most commonly the right anterior, right posterior, and left lateral position.
Internal hemorrhoids arise above dentate line and covered by transitional or columnar epithelium. They may prolapse and may be reducible or may be irreducible. They arise from superior hemorrhoidal plexus.
Mixed hemorrhoids (external, internal) may be prolapsed, irreducible, thrombosed, or ulcerated. They arise from superior and inferior hemorrhoidal plexi and their anastomotic connections.
First-degree hemorrhoids, veins of anal canal are increased in number and size and may bleed at the time of defecation. They do not prolapse but project into the lumen.
Second-degree hemorrhoids present to the outside during defecation but return within the anal canal spontaneously.
Third-degree hemorrhoids (internal, external) protrude outside the canal anal and require manual reduction.
Forth-degree hemorrhoids are irreducible and remain in the prolapsed position at all time.
An accurate diagnosis can be made by taking a careful history. Since bleeding is the most presenting symptom, questions should be asked about not only the amount of blood but also the color, whether the bleeding is painful, mixed with stool. Questions about bowel habits, abdominal pain, sensation of burning, incomplete emptying with bowel movements, fullness, bulging.
Evaluation include general medical condition, bleeding problems, portal hypertension, chronic constipation, intermittent diarrhea.
Physical examination is directed on the abdomen, the groin area, the genitalia, the appearance of the perineum and the condition of the skin.
The patient is examined in the supine, left lateral, or Jackknife position. Digital rectal examination palpate the most external portion of the anus, the middle canal and the entire canal and anorectal ring is examined. The degree of anal tone is assessed, the relative length, and its spasticity.
Anuscope is the most important method of exposing the entire anal canal to the level of anorectal ring. Rigid sigmoidoscope will discover pathological conditions in the first 20 cm above the anorectal ring. If the history of the patient is suggestive of other abnormalities, the investigation will be completed by a double-contrast barium and colonoscopy.
There is constant evolution in the surgical treatment of hemorrhoids. Modifications on this subject have evolved over time from open to closed method of excisional hemorrhoidectomy. Hippocrates performed most likely an open hemorrhoidectomy 2000 years ago, In the middle Ages, hemorrhoids were most probably treated with mass ligation of the entire internal and external hemorrhoidal complex. Over 2000 years ago the French anatomist Jean Louie Petit recognized the sensitivity of hemorrhoidal epithelium and tried to excise hemorrhoids without denuding the lower anal canal of its mucosa. In 1959, Ferguson and Heaton described the Ferguson technique of closed hemorrhoidectomy since that time, closed hemorrhoidectomy has become widely accepted and practiced. In 1882, Whitehead, a British surgeon, described a circumferential amputation of hemorrhoids. Every surgical treatment of hemorrhoids results in complications that are classified as early or late complication. Complications due to surgical difficulties (Parks hemorrhoidectomy) which is bloody and tedious to perform and complications due to the location of the surgical procedure such as ano-rectum which is a functional anatomical region for stools and gas to be eliminated regularly.
Other forms of therapy are described with variable results: sclerotherapy, forceful anal dilatation, elastic band ligation, infrared coagulation, cryogenic coagulation, and laser hemorrhoidectomy.
It would be highly desirable to be provided with a new and rapid office procedure done under local or loco-regional anesthesia for removing hemorrhoids.
One aim of the present invention is to provide a new and rapid office procedure done under local or loco-regional anesthesia for removing hemorrhoids
In accordance with the present invention there is provided a new surgical procedure for removing hemorrhoids as described herein. More particularly, there is provided a method for removing a hemorrhoidal mass from a patient, said method comprising sequentially the steps of:
a) isolating an hemorrhoidal mass from a patient with a forceps applied at the base of said hemorrhoidal mass, said forceps having a proximal side in contact with the perianal region of the patient and a distal side in contact with the hemorrhoidal mass;
b) suturing on the proximal side of the forceps the tissue of the perianal region along said forceps to cause hemostasis in the hemorrhoidal mass;
c) cutting off from the patient on the distal side of the forceps the hemorrhoidal mass; and
d) removing the forceps from the patient.
When suturing in step b), proximal and distal threads are preferably left to control a possible hemorrhage by pulling said threads in opposite direction. Additional forceps may also be placed at the perianal region for exposing the hemorrhoidal mass.
The innovative surgical hemorrhoidectomy of the present invention is very easy to perform. It is an office procedure, done always under local anesthesia, and has almost no complications due to surgical technique itself.